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Bridging the Divide: Can Naturopathic and Medical Doctors Collaborate to Make Integrative Care A Reality?

Aaron Van Gaver, Vanessa Vaartnou

Integrative healthcare is defined as an avenue of medicine and health that ”reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare, and disciplines to achieve optimal health and healing.”[1] For the purposes of this article, naturopathic doctors are the alternative approach. The term ‘integrative care’ is, in the current healthcare climate, simply an ideal. It is an idealized system for streamlining patient care — where the strengths of each profession, both naturopathic and conventional, are realized, and patients are directed to the appropriate practitioner for care. Vancouver is especially flooded with clinics operating under this apparently integrative model. While these operations are headed in a positive direction, they still have a ways to go before fully operating under the umbrella of true integrative care. My ten plus years of practice as a naturopathic physician in a healthcare system that has undergone extensive changes has created a unique perspective on the integrative healthcare model.

This is the healthcare world I would like to operate within. However, I am not blind to the reality that we have a long way to go before that ideal system can be realized. As a naturopathic physician, I have had the benefit of seeing the ‘other’ side of healthcare—the side that the allopathic medical doctor (MD) is not always privileged to witness and participate in. For example, I often see patients who have exhausted conventional resources and still show no improvement in their health. I see patients who explore alternatives because they are not getting better. Unfortunately, by the time I have the opportunity to work with these types of patients, they are frustrated and have spent both time and money without receiving any apparent benefits. The beauty of an integrative care model is the potential to streamline patients to the appropriate medical model. In many cases, a synergy can exist when both the conventional and naturopathic approaches are applied to a patient’s case. For this to happen, however, the two professions have to understand the strengths and weaknesses of both approaches. It is vital that we as physicians recognize the following: when one approach is better suited over the other, understand how the two professions can work in tandem, and most importantly trust the treatment plan of the other doctor. Essentially, we must keep an open mind for true integrative care to become a reality.

Our two professions have come a long way in working alongside each other, and naturopathic doctors have gained ground and respect as medical practitioners, with the scope of practice continuing to evolve. There are four primary objectives for scope of practice for British Columbia naturopathic doctors.[2] With these goals in mind, the British Columbia Naturopathic Association (BCNA) works tirelessly to expand the scope of naturopathic practice. These goals include prescribing rights, laboratory and diagnostic access, specialist referral, and hospital privileges.[2] In 2009, the first of these pillars was realized, with naturopathic doctors gaining prescribing privileges. Naturopathic doctors have the ability to order laboratory testing; however, patients are required to pay for each test. In addition to prescribing privileges, naturopathic doctors incorporate various modalities into patient treatment plans. These may include acupuncture, manual therapies (osseous manipulation, electrotherapy), injection therapies (neural therapy, prolotherapy), botanical medicine, use of neutraceuticals, and medical nutrition. Naturopathic doctors receive extensive training in these modalities and are able to make clinical judgments as to when one is indicated over another. A vital aspect of naturopathic education is a thorough understanding of how these many modalities interact with each other when they are best implemented.

In British Columbia, naturopathic medicine was added to the Health Professions Act in 1996.[3] Since then, we have become a self–regulating profession, providing support to our mutual patients while ensuring public safety by setting stringent guidelines for our education and training. Our scope of practice is still growing and we continue to be self–regulated under the College of Naturopathic Physicians of British Columbia (CNPBC). The greater the scope of naturopathic practice, the more equipped naturopathic physicians are to utilize our extensive training to manage cases as primary care practitioners (PCP). Increasing the scope of practice of naturopathic doctors further facilitates the creation of an integrative care system. The B.C. government has repeatedly highlighted the need for additional PCPs.[4,5,6] Incentives for newly graduated doctors to work in rural communities exist; however, many city–dwellers also lack a PCP.[4] Both the premier and current minister of health have voiced the shortfalls of the current healthcare system and continue to focus on the “GP for Me” program, which seeks to ensure B.C. residents have a PCP.[7] Naturopathic doctors have the potential to be part of the solution. Naturopathic doctors are currently licensed as PCPs who specialize in natural medicine, but our current scope of practice is limiting. By practicing to our full potential and training, naturopathic physicians can, under an integrative model, alleviate the strain on the current system.

In my 12 years of practice in downtown Vancouver, I have witnessed tremendous growth between the two professions. In the past, I have had to fight for copies of patient test results, including blood work or ultrasound results, but I have since learned to respect the authority of the general practitioner (GP) and educate the patient on their options. Currently, any patient who comes to see me goes through an initial intake, which can involve a full health history and physical exam. Depending on the chief concern, this can take anywhere from 30 to 90 minutes. Patients frequently seek out a naturopathic doctor because he or she wants assurance they are living a healthy life; this is where the naturopathic doctor excels. The strength of the naturopathic approach is that we, as naturopathic doctors, take inventory of many facets of a patient’s lifestyle. These include social history, family history, dietary habits, environmental stressors, emotional state, current medical treatments, and a review of systems. We do this because we believe it is necessary to treat the whole person, not just the individual symptom or system. This, in turn, provides us with valuable information to create targeted treatment protocols and work with the patient to treat the root cause of their ailment. In other cases, where the patient simply wants lifestyle support, gathering this degree of information facilitates preventing disease later on.

In the current system, where the ideal integrative model does not yet fully exist, there are several hurdles for patients who seek alternative care. If their GP is not open to complementary care from other health professionals, it potentially isolates that patient. I have experienced patients requesting that I do not communicate with or send lab results to their family doctor for fear of ruining that relationship. This is not a positive experience for the patient and something we should seek to avoid. Why can’t the patient feel free to explore other options? Why must their healthcare be managed by one avenue of medicine or, in some cases, an individual? I believe they should feel free to seek out additional care and utilize the strengths of other healthcare practitioners. The same goes for my profession: there are times when I have witnessed naturopathic doctors taking patients off of medications and instead recommending supplements in their place without regard for our MD counterpart’s treatment plan. There needs to be a better way for our two professions to interact. Improving the relationship between our two professions will facilitate better patient experiences, and ideally, more positive patient outcomes.

The 2002 Romanow Report demonstrates the need and desire of Canadians for a more comprehensive healthcare system.[8] He outlines a collaborative system where individuals receive care from a multitude of healthcare services delivered in a seamless fashion, as opposed to receiving isolated care from many healthcare practitioners. In his report, Romanow discusses the need for an integrative approach that works on prevention, promotion, primary care, community health, and mental health. This extensive report was a huge step for the naturopathic profession; in discussing the shortfalls of the current healthcare system, it created a niche for naturopathic doctors to exist in an integrative care model. It highlighted the importance of healthcare practitioners working together under an integrative model to streamline patient care.

The current healthcare climate in British Columbia requires a revamp. Both the Romanow report and the B.C. Ministry of Health [6] outline a shift in direction for our current system. Romanow discusses the need to re–evaluate key determinants of health. The B.C. Ministry of Health suggests several health goals for British Columbians, which can be addressed by moving towards an integrative health model.[5,6] If we as healthcare professionals hope to empower a patient to live a healthier life, reduce the burden to healthcare, and improve patient experience, naturopathic and allopathic physicians need to start working together.

We do have a few areas where this integration has been easier; for example, in the oncology world, medical and naturopathic doctors work alongside each other at the Cancer Treatment Centers of America (CTCA), and there are a number of local naturopathic doctors who work with Inspire Health. Chronic care is another area where naturopathic doctors excel, and in several integrative clinics in the Vancouver area, naturopathic and medical doctors co-manage cases. Naturopathic doctors have the luxury of longer patient visits, which lends well to these types of cases.

While a plethora of positives for integrative care exist, implementing this model is not without potential consequences. First and foremost, a clear definition is needed.[9] This definition must clearly define the types of practitioners involved and their specific roles.[9] It may be necessary to differentiate the naturopathic doctor from other alternative healthcare practitioners who lack the extensive science–based clinical education. In addition, a major barrier is the potential for mismanagement. Without a clear definition of physician roles there is the potential for patients to fall through the cracks. For example, monitoring a patient on a specific drug begs the question of who is the initial prescriber and which physician is ultimately responsible for following that patient’s progress. For this to work, naturopathic and medical doctors must recognize and respect each other’s judgment. On the flip side, the integrative model, in a world of specialists, has the potential to ensure a sole physician monitors a patient’s diverse care. In the current system, a GP has limited time with each patient to oversee cases managed by multiple physicians. In addition to the potential mismanagement of an integrative system, is the significant barrier of a naturopathic doctor’s fee for service. Naturopathic doctors are able to spend significantly more time per patient visit because they are paid privately. While every naturopathic doctor employs a different fee schedule, ultimately our services are more accessible to individuals who can afford to pay. If we hope to provide equal access to B.C. residents, this aspect would need to be addressed.

While our two professions have made great strides in working together, there is still a ways to go. As each profession continues to recognize the strengths of the other and how these strengths can best benefit a patient’s case, patients will be more effectively and efficiently cared for. A true integrative model is the ideal, and we are a ways from making it a reality. However, with an open mind and a willingness to take a few small steps in the short term, I believe it can be realized in the future.

DISCLOSURES

Dr. Van Gaver is a board director on both the BC Naturopathic Association and the Canadian Association of Naturopathic Doctors. He has no conflicts of interest to disclose.

EDITORIAL STATEMENT

Traditionally, students studying in Canadian medical schools have little exposure to naturopathy. The UBCMJ sought to present a naturopathic practitioner’s perspective on integrative medicine. In this article, Dr. Van Gaver presents his ideas on the challenges and benefits of integrating naturopathic and conventional Western medicine. The views expressed in this article are solely those of the author(s) and do not necessarily reflect the ideas or values of the UBCMJ or the Faculty of Medicine.